Infectious Disease Control
When the story of 2020 is written, it will begin with a bug—a virus that began in Wuhan, China, and then raced around the world.
Dr. Tedros Adhanom Ghebreyesus (WHO): “COVID-19 can be characterized as a pandemic.”
BBC reporter: “The situation is dire.”
CNBC reporter: “The market has just tanked.”
ABC anchor: “Chaos at America’s airports.”
Spanish Prime Minister Pedro Sánchez: “El estado de alarma.” (The state of emergency)
French President Emmanuel Macron (in French): “Living if nothing had happened, we said this is no longer possible, it’s stupid.”
U.K. Prime Minister Boris Johnson: “This is the worst public health crisis for a generation.”
Victim: “The fever is so high that you hallucinate.”
Global National reporter: “Most stores, restaurants and entertainment facilities will be closed.”
France 24 reporter: “The mortuary is full. They’re having to put some of the bodies in a church.”
Dr. Anthony Fauci: “Things will get worse before they get better.”
Although this virus may be new, we have faced deadly epidemics before. Today on Projectified®, the story of how project leaders worked with the medical community, government leaders and local stakeholders to snuff out a virus that killed 50 percent of those infected, and what we can learn as we look at the current crisis and beyond.
The world is changing fast. And every day, project professionals are turning ideas into reality—delivering value to their organizations and society as a whole. On Projectified®, we’ll help you stay on top of the trends and see what’s ahead for The Project Economy—and your career.
This is Projectified®. I’m Steve Hendershot.
That voiceover bit you just heard—“the world is changing fast”—when we recorded that, we had no idea just how quickly the world was about to change and would continue to change, day by day, hour by hour, because of this coronavirus outbreak.
In Wuhan, China, the government built a 1,000-bed hospital in just 10 days to accommodate the sick.
In Italy, overwhelmed hospitals turned to 3D printers to create replacement valves for their ventilators.
In South Korea, the government sends its citizens a text message whenever someone in their area tests positive for the coronavirus.
These projects are literally saving lives while we wait for a vaccine.
There’s no predicting the timing of a pandemic like this, not even for specialists in epidemic response like Dr. Ranu Dhillon. For us, as well as for them, life can change in an instant.
Dr. Dhillon was on the faculty of Harvard University’s Brigham and Women’s Hospital in 2014—he still works there, in fact—but back then he was monitoring the early days of the Ebola outbreak from afar and publishing about how developing countries could better deliver primary care. When his research found its way to one particular world leader, everything changed as he flew off to fight the disease up close.
Fast-forward to the coronavirus crisis, and Dr. Dhillon is back home in the U.S., applying his expertise to the efforts to stop the spread of a pandemic that threatens his own community. We spoke to him about his experience fighting Ebola, as well as his take on what he’s facing now.
Let’s talk about your work in Guinea. Where did that connection come from? First of all, were you a professional observer before you were pulled to the front lines, or how did you get involved?
So, much of the work that I did up until that point and that I still primarily focus on is how to develop primary health systems in poor countries. And so I had done that work for a number of years, including spending a couple of years as an adviser to the Ministry of Health in Liberia. And when the Ebola epidemic was really spiraling out of control in West Africa, I was hearing a lot from colleagues that I had worked with in Liberia about what was happening on the ground. So it was natural for me to sort of take interest in finding out more what’s happening there.
And from looking at the situation, a lot of the challenges to responding to Ebola are analogous to me to the challenges of creating a health system to deliver primary healthcare. And that’s really identifying the people you need to reach and the systematic chain of interventions you need in order to get them the services they require.
And from discussing that with some colleagues, we came up with what we thought was a strategy that needed to be implemented across West Africa to counter the Ebola epidemic, and we ended up getting that published. And the president of Guinea read it, and two days after reading it he called us in for a meeting. He was in Washington, D.C., at the time, I think for discussions with the World Bank to get support for building up the response.
So we actually met in Washington, D.C., and that same day he asked if I could fly back with him to Guinea the next day and see that they were doing all the things they needed to do in order to get the epidemic under control.
And so the next day, I flew with him to Guinea, thinking I’d be there for about a week just to see that all the elements of the response were in place, but it seemed that there was a lot more work to do, and I ended up being there for over a year, working with the president’s office but also with the Ministry of Health there, local governments there and an array of different partners, including WHO and CDC to really build up a strategy for controlling the epidemic and then the tougher part being figuring out how to operationalize and implement that strategy really at scale across a country where logistics and other infrastructure was lacking.
So I ended up being there for an extended period of time, but we were able to be successful in creating a strong and robust response and ultimately getting that epidemic under control.
Leaving the actual work aside, just characterize the sort of psychological difference being there on the ground compared to sort of developing the paper from a distance.
It’s so easy to have a certain viewpoint of things when you’re just hearing about things from afar and through media, and then the ground-level reality’s very different. You know, I think some of the principles of epidemic response, those are the same from wherever you’re looking at an epidemic. But once you’re on the ground, you actually understand what the challenges truly are.
And so, for example, from afar it seemed like there was just uncontrolled transmission, that there was, quote, “distrust of government” and other challenges of that sort. Those were certainly there, but when you actually got on the ground you saw that a lot of this had to do with history.
So much of what was happening with the epidemic, the hot spots we were seeing, it almost mapped perfectly onto the places where there was different political contentions and different political history. And from looking at it from afar, you would never see that nuance, but when you’re on the ground that nuance was really what we needed to figure out how to get around or tap into in order to get communities engaged in the way that they needed to in order for us to intervene in the way we needed with contact tracing and other measures, as well as for communities to take the steps they needed to to prevent themselves from getting infected.
We were constantly in contact with our counterparts in Sierra Leone and Liberia and learning from each other about what was working, what was not working and really trying to adapt strategies. At the end of the day, some of the strategies that worked in Liberia could never really fly in Guinea because we’re talking about a different social and political backdrop. But at the same time, there were things we were able to mobilize around in Guinea that Liberia couldn’t do.
And as you get closer to sort of front-line delivery, is there, I mean this seems like something when you get into your line of work that has to be part of the conversation, but how do you approach the emotional aspect? I mean, I feel like there’s a high stress level related to the current COVID-19 crisis and then you, you know, multiply that by the mortality rates associated with Ebola—how did you approach that? How did the teams there approach that?
For a number of years now I’ve worked in places where we do have high mortality and, in fact, an area of Rwanda where we started working in 2005, for example, there’s a village where we were setting up a model project, sort of a model for how the health system could function in concert with the government.
When we first entered into that village, they were having maybe 1 out of every 5, 1 out of every 4 children die before they turned 5. And so you see large amounts of mortality that really shouldn’t be happening, and so I think over some years you develop some way of processing that or compartmentalizing it, especially when you’re in the moment and you need to be able to react and respond.
I think it’s probably analogous to when I’m working in the hospital and you have a very sick patient in front of you, and certainly there’s so many reasons to be caught up in the emotion of the moment, but you almost have to keep yourself focused on the technocratic kind of strategies and tasks that you need to implement.
Another element of it was that it was 24/7. Literally you’re kind of around the clock. There’s always, “Where are new cases arising? What happened with the contact tracing in this place? Why is there a new case in this neighborhood? Which transmission chain did it come from, or is there transmission that we don’t know about that’s happening off the radar?”
It’s sort of a constant, 24/7 chasing of the epidemic, and I think just sort of that intensity of always being focused on it also I think buffers your mind a little bit from the emotional weight of what’s going on in front of you. And you know, the most important part of it is that it’s one thing for me to be there and see this and see this happening to families and the emotion I feel, but I see these very same families, the loved ones who are losing loved ones, I see them step up and the next day come and want to be contact tracers, come and want to engage neighboring villages that had up until that point maybe been resistant towards any Ebola response activities.
And when you see that type of resilience, that type of courage in the people who are most affected, that leaves you little reason for you to, you know, feel bad to yourself and just feel inspired and motivated that seeing the sorrow you’re seeing, you need to figure out a way to end it.
And I think that was sort of the most compelling part of being on the ground and being that close to it is that you’re constantly reenergized by the people who are going through it firsthand and who are working alongside you firsthand.
I can imagine you’re not constantly being reenergized though, and that fatigue becomes a real issue. How does that affect the overall effort?
Fatigue does become an issue, mostly because in an epidemic transmission is mathematical in the sense that it’s just, it’s happening and it’s not really caring about weekends, it’s not really caring about Christmas holidays, it’s not caring about any other parts of life where we have momentary pauses. And it’s just going to keep going unless you build the system to counter it.
I’ll leave the state nameless, but I know in a particular state right now where there is transmission, the PCR testing labs are not open on Sunday, for example. And I understand people need rest, and that’s part of all of this, but, you know, there’s, we’re in a situation where we’re heading towards the peak of an epidemic. We really should be working 24/7 to really get ahead of it. And the fact that testing can’t be done for a whole day out of a week is really problematic when that actually has consequences for transmission and patient care.
What were the big lessons learned or sort of victories? Obviously you sort of have the on-the-ground experience of strategies you employed as well as those you recommended in your paper, so what ended up being the key takeaways to join the infectious disease playbook in outbreaks since then and the current one, if there are any applicable?
Yeah, so, you know, very kind of ironically and painfully, one of the main lessons we learned was the value of early detection. This was the big challenge in West African Ebola epidemic from the beginning. And that was that you were having lots of transmission. There were many transmission chains we didn’t know about, meaning people were getting infected from people and places that were off the radar of any surveillance or response agencies, such that you would assume that there might be a lot of cases that we just don’t know about, a lot of people getting infected that we don’t know about.
And once that happens, there’s really no easy way to then figure out who is infected and who’s not. The challenge with Ebola, similar to what we’re seeing with coronavirus, is people present with symptoms that are the same as almost any other common condition in those areas.
So in the U.S., you know, for example, I’m being tested for coronavirus right now because over the weekend, I had flu-like symptoms. Now, flu-like symptoms can be caused by any number of viruses, but there’s no way to know that it’s not coronavirus. And I live in an area where you do have community transmission.
Similarly, in West Africa with Ebola, we had patients coming forward with fever, diarrhea, body aches. That could be Ebola. That could also be malaria, which is extremely common in that area. That could be pneumonia. That could be any number of different conditions. And the problem was, there was no way to say who had Ebola and who didn’t and distinguish them.
And you’re stuck in this situation where literally the thousands of people who have fever every day, you have to assume they might have Ebola, and there’s no way to tell if they do or don’t. You can then isolate them until you can test them, but we were having a situation where we couldn’t isolate that many people for testing.
And people were being held in rooms with other people who may have Ebola, and maybe they didn’t have Ebola coming in, but then they got infected by the person who was sitting next to them while waiting for testing. It was a big challenge.
And the reason for that challenge is the same thing we’re actually facing in the U.S. now, which is that you need to have decentralized and rapidly scalable testing capacity. And with PCR labs, certainly in West Africa, we did not see that that was going to be able to scale wide enough, because it requires a lot of specialized personnel, a lot of specialized equipment, a lot of specialized infrastructure. And so there’s no way you can PCR test literally thousands of people presenting with fever every day.
And what you really needed was a rapid diagnostic test. And so one of the big takeaways from our experience with Ebola is you need to have rapid diagnostic tests that are sort of like urine pregnancy tests, where you can administer them relatively quickly and easily, meaning you don’t need a specialized lab person to administer it. So people can either self-administer it, or you can train community health workers, nurses to administer it.
And you get results relatively quickly, not two, three days like we have with PCR in the U.S., but more like 20 minutes, an hour. And that way, very quickly, you can determine who is infected and who’s not.
The coronavirus pandemic has been a very different situation in terms of testing, both because the tests have been in short supply in many places and also because it seems people can be contagious without presenting symptoms. How would you describe the challenge that that presents in terms of taking advantage of early detection strategies?
So I’ll give you a quick analogy. If you could put something in the air where everyone who has coronavirus right now turned green, where you could tell this person has coronavirus, and then automatically, a bubble forms around them for the two weeks when they might be infectious, this, you know, that, if we could magically do that, this epidemic would be over in two weeks, because everyone who’s infected, asymptomatically carrying, also turns green. There’s a bubble around them where they can’t infect anyone else. In two weeks, this is over.
So in some sense, you know, what we’re almost trying to say is that sounds like a silly kind of thought experiment, but it really is analogous to what you’re almost trying to do with early detection and isolation and with mass testing.
Does this feel different personally, because this time you’re not parachuting in—this time there’s already community transmission in the city where you live?
Yeah, it definitely feels different. But I think some of that has to do with a couple of other things. I, on one level, I’m not trying to be complacent about being infected with coronavirus, but at a personal level, it’s, to me, it’s more a concern of transmission than me personally being infected. You know, certainly there’s cases of people who are healthy, and relatively younger who have gotten very sick, so I’m not trying to be naive about that, but I think the sort of personal risk is not the same with, in most instances, if I got infected, the illness would probably be mild. You know, Ebola, of course, is a different story.
So there’s, on a personal level, it’s sort of a difference in that, so the role I play, or the way I see myself being involved also becomes a little bit different, because there’s not that level of kind of fear of infection that’s there and the fact that, you know, this virus, it’s going to infect people. It’s already out of the bag. Ebola was out of the bag in West Africa, but Ebola you could not leave out of the bag in any manner, just because it’s so lethal.
And so I think the fact that this causes milder illness makes it a very different kind of epidemic. The other part of it is, I think when I got involved with the response in Guinea, it was, like, a chance meeting, but also one of the opportunities that came with that was that I really had the support and the weight of the president behind me to push for things to happen.
So, you know, if we felt like certain things needed to happen, we had sort of executive power. We had the ability to marshal resources and push things and get them done, and get them done quickly.
And you know, as I find myself getting involved with how we’re responding to coronavirus, especially here in the U.S., it’s a little bit of a different story in that, I think it’s a little bit harder to push a clear agenda forward. I think there’s not just more voices, but the systems are not created where, you know, there’s centralized power that can drive action, for better, and worse, of course.
And I think that makes it very different too, because here it’s, you know, there may be certain things that are clear that you want to act on and do, but the pieces that have to be put into place, the players that have to be engaged in order to act in that manner, it’s really tough to sometimes align that and align it with federal level, align it with state level, align it with local level.
So I think the backdrop, and I guess in the standpoint of political structure, it’s very different. And I think that makes how this response will play out a very different thing.
One of the defining features of this coronavirus outbreak has been constant uncertainty, stress and the feeling of unsteady ground beneath our feet. That’s been true for Ranu Dhillon as well.
Shortly after I spoke to him, his test came back negative, meaning he was able to race back to the front lines of this global battle.
But Ranu’s run-in with the virus on the most personal of terms underscores the challenge facing project leaders, who must struggle to formulate and coordinate a winning response, even as the conditions around them continue to change—even with their own health. It’s a campaign that drains them physically, psychologically, intellectually, relationally, yet one that they continue to push forward, using their skills to make a crucial, meaningful difference. For that, the rest of us are deeply grateful.
As we record this, COVID-19, the coronavirus, appears ready to test all our systems, and project teams around the world will face challenges large and small. Governments will need to maintain order, supply chains have to keep moving, hospitals must hold up despite the strains on nearly all their systems, and parents have to hold up, too, as they figure out how to work remotely with their children home from school.
Even in the face of a pandemic, project work continues, and so must we.
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